Chimeric anterolateral thigh free flap for head and neck reconstruction

The free chimeric medial sural artery perforator flap for individualised and three-dimensional reconstruction of complex soft-tissue defects in extremities

Trauma or lesion resection often causes complex wounds with deep soft tissue defects in extremities. Simply covering with a skin flap will leave a deep dead space resulting in infection, non-healing wounds, and poor long-term outcomes. Thus, effectively reconstructing complex wounds with dead space leaves a clinical challenge. This manuscript presents our experience using chimeric medial sural artery perforator (cMSAP) flap, to reconstruct complex soft tissue defects of the extremities, thereby exploring broader analysis and indications for future reference. Between March 2016 and May 11, 2022, patients (8 males and 3 females) with a mean age of 41 years (range from 26 to 55 years) underwent reconstructive surgery with the cMSAP flap. The cMSAP flap consists of an MSAP skin paddle and a medial sural muscle paddle. The size of the MSAP skin paddle ranged between 9 × 5 cm and 20 × 6 cm, and the size of the medial sural muscle paddle ranged between 2 × 2 cm and 14 × 4 cm. Primary closure of the donor site was achieved in all cases. Of the 11 patients, the cMSAP flap survived in 10 cases. The vascular compromise occurred in one special case and was treated with surgical procedures. The mean follow-up duration was 16.5 months (range of 5-25 months). Most patients present satisfactory cosmetic and functional results. The free cMSAP flap is a good option for reconstructing complex soft tissue defects with deep dead space in extremities. The skin flap can cover the skin defect, and the muscle flap can fill the dead space against infection. In addition, three types of cMSAP flaps can be used in a broader range of complex wounds. This procedure can achieve an individualised and three-dimensional reconstruction of the defects and minimise the donor site morbidities.

Is the oblique branch of the lateral circumflex femoral artery a common variant?

The oblique branch of the lateral circumflex femoral artery, a short branch of the deep femoral artery, is highly prevalent (32-46%) and is usually considered a normal variant, although this is still controversial. This study aimed to evaluate whether the oblique branch of the lateral circumflex femoral artery is a variant. We reviewed medical record data of patients with skin and soft tissue defects of the extremities who underwent flap repair using free anterolateral thigh (ALT) flaps at our hospital in 2019. The anatomical characteristics of the flaps were examined intraoperatively by high-frequency color Doppler ultrasound. A total of 153 ALT flaps from 146 patients were included. Among the branches, 232 (73.7%) were oblique branches, and 83 (26.4%) were descending branches. Of the 232 oblique branches, 141 (60.8%) were from septocutaneous branches, and the other 83 (39.2%) were from musculocutaneous branches. In addition, 20 (24.1%) descending branches were from septocutaneous branches, and the other 63 (75.9%) were from musculocutaneous branches. Analyzing the prevalence of the oblique branch in septocutaneous branches, more than half of the patients had oblique branches rather than descending branches. The high proportion of oblique branches from septocutaneous branches (median: 100 (0-100) vs. 0 (0-50), p = 0.002) supports the understanding that the oblique branch is a normal anatomical element rather than a variant. The main type was the intramuscular branches, which required significantly less time for flap harvesting. The oblique branch may be the preferred vascular pedicle for free ALT flaps.

Individualized design of double skin paddle anterolateral thigh perforator flaps to repair complex soft tissue defects of the extremities: An anatomical study and retrospective cohort study

This study describes our experience using individually designed double skin paddle anterolateral thigh perforator (ALTP) flaps to reconstruct complex soft tissue defects. An anatomical study of double skin paddle ALTP flaps was conducted in six fresh cadavers (12 thighs). We also performed a retrospective cohort study of 36 patients who underwent reconstruction using double skin paddle ALTP flaps from January 2009 to June 2019. The soft tissue defects were large or non-adjacent defects that could not be repaired by a single flap. Three types of double skin paddle ALTP flaps were designed. In type I, separate perforators supplied each flap: one perforator from the transverse branch of the lateral circumflex femoral artery (LCFA) and one from the descending branch of the LCFA (d-LCFA). In type II, both perforators were from the d-LCFA. In type III, a single perforator from the d-LCFA had two branches that each supplied one flap. In the cadaver study, type I was observed in 11 thighs, type II in 10, and type III in six. All patients were successfully treated using double skin paddle ALTP flaps. Four patients received type I flaps, 23 received type II, and nine received type III. Vascular compromise occurred in one patient, and the flap was saved by emergency revascularization. Most patients had satisfactory contours and functional recovery during follow-up. Individually designed double skin paddle ALTP flaps is a reliable option for reconstructing complex soft tissue defects. Moreover, we created an algorithm for microvascular reconstruction of complex soft tissue defects.

Pre-expanded bipedicled visor flap: an ideal option for the reconstruction of upper and lower lip defects postburn in Asian males

Background

Reconstruction of upper and lower lip subunits is a complicated and elusive challenge. For patients affected by defects involving upper and lower lip subunits, a technique able to reconstruct both aesthetic units with matched colour, sufficient contours and similar texture would be ideal. In this study, we present our experience with upper and lower lip reconstruction using the pre-expanded bipedicled visor flap.

Methods

From January 2014 to January 2017, 12 male patients presenting with defects of the upper and lower lip subunits were treated using this surgical technique. After a period of expansion of the scalp flap of over 6 months, the bipedicled visor flap was raised from both the parietal regions and rotated to resurface the defect. Delay and section of the pedicle were then performed.

Results

Twelve male patients with postburn scars aged 22 to 48 years (mean: 34 years) were successfully treated with no major complications. The donor site was closed primarily in all cases. Subsequent flap debulking and minor revisions were performed under local anaesthesia between 6 and 12 months postoperatively.

Conclusions

The pre-expanded bipedicled visor flap provides an effective and reliable option for upper and lower lip reconstruction with excellent colour and texture. It is feasible to achieve these results simultaneously from a single donor site by using a pre-expanded bipedicled visor flap.

Reconstruction of composite oral and maxillofacial defects by free flaps based on a new classification

Reconstruction of composite oral and maxillofacial defects using free flaps is challenging. The key to such delicate reconstruction lies in the evaluation of the defect. However, few reports have described the clinical classification of these difficult defects. In this study, we proposed a classification method and developed different reconstructive solutions using free flap techniques according to this classification. This classification method was established based on two parameters (the elements and distribution of the missing tissues). Among the 17 patients with composite oral and maxillofacial defects included in this study, 8 patients presented with type A defects, one patient presented with a type B defect, and the other 8 patients presented with type C defects. No type D defects were observed in this study. Three types of free flaps were used to reconstruct the respective types of composite defects. Perforator-based ALT flaps were used to reconstruct Type A defects. Branch-based ALT flaps were used to reconstruct Type B defects. For Type C defects, two reconstructive solutions were used, including a well-designed fibular flap and a perforator-based ALT flap with or without a metal plate for bony reconstruction. All flaps survived after surgery. This classification system may help select and design specific free flaps for reconstructing composite oral and maxillofacial defects.

Reconstruction of Near-Total Loss of the Upper and Lower Lips due to Purpura Fulminans with Local Tissue and a Dual-Skin Paddled Anterolateral Thigh Flap

It is difficult to totally reconstruct the lip, achieving good functional and aesthetic results. There have been few reports of reconstructing complete lip defects. Moreover, upper and lower lip necrosis by purpura fulminans has not been reported. We present a case of a 60-year-old male purpura fulminans patient with upper and lower lip necrosis. Fortunately, our patient had retained his oral commissure function. We reconstructed this defect with an orbicularis oris muscle-skin-mucosal pedicled flap derived from the region between the nasolabial folds for upper lip; a similar bipedicled flap for the lower lip and the donor site was closed with a dual-skin paddled anterolateral thigh flap. Postoperative results were satisfactory, that is, no lip tightness or aperture restriction was seen, and symmetry had been achieved. The new lips exhibited complete sensory recovery. Drooling was minimal during rest and feeding. We could select a method that combined the advantages of local and free flaps. We consider our method for this defect is superior to those described in previous studies, in that the restoration of lip sensation and oral sphincter function can be achieved to some extent in 1 stage while preserving the oral commissure function.

Perforator chimerism for the reconstruction of complex defects: A new chimeric free flap classification system

Complex defects present structural and functional challenges to reconstructive surgeons. When compared to multiple free flaps or staged reconstruction, the use of chimeric flaps to reconstruct such defects have many advantages such as reduced number of operative procedures and donor site morbidity as well as preservation of recipient vessels. With increased popularity of perforator flaps, chimeric flaps' harvest and design has benefited from 'perforator concept' towards more versatile and better reconstruction solutions. This article discusses perforator based chimeric flaps and presents a practice based classification system that incorporates the perforator flap concept into "Perforator Chimerism". The authors analyzed a variety of chimeric patterns used in 31 consecutive cases to present illustrative case series and their new classification system. Accordingly, chimeric flaps are classified into four types. Type I: Classical Chimerism, Type II: Anastomotic Chimerism, Type III: Perforator Chimerism and Type IV Mixed Chimerism. Types I on specific source vessel anatomy whilst Type II requires microvascular anastomosis to create the chimeric reconstructive solution. Type III chimeric flaps utilizes the perforator concept to raise two components of tissues without microvascular anastomosis between them. Type IV chimeric flaps are mixed type flaps comprising any combination of Types I to III. Incorporation of the perforator concept in planning and designing chimeric flaps has allowed safe, effective and aesthetically superior reconstruction of complex defects. The new classification system aids reconstructive surgeons and trainees to understand chimeric flaps design, facilitating effective incorporation of this important reconstructive technique into the armamentarium of the reconstruction toolbox.

Microsurgical free flaps: Controversies in maxillofacial reconstruction

Reconstructive microsurgery for oral and maxillofacial (OMF) defects is considered as a niche specialty and is performed regularly only in a handful of centers. Till recently the pectoralis major myocutaneous flap (PMMC) was considered to be the benchmark for OMF reconstruction. This philosophy is changing fast with rapid advancement in reconstructive microsurgery. Due to improvement in instrumentation and the development of finer techniques of flap harvesting we can positively state that microsurgery has come of age. Better techniques, microscopes and micro instruments enable us to do things previously unimaginable. Supramicrosurgery and ultrathin flaps are a testimony to this. Years of innovation in reconstructive microsurgery have given us a reasonably good number of very excellent flaps. Tremendous work has been put into producing some exceptionally brilliant research articles, sometimes contradicting each other. This has led to the need for clarity in some areas in this field. This article will review some controversies in reconstructive microsurgery and analyze some of the most common microvascular free flaps (MFF) used in OMF reconstruction. It aims to buttress the fact that three flaps-the radial forearm free flap (RFFF), anterolateral thigh flap (ALT) and fibula are the ones most expedient in the surgeon's arsenal, since they can cater to almost all sizeable defects we come across after ablative surgery in the OMF region. They can thus aptly be titled as the workhorses of OMF reconstruction with regard to free flaps.

The expanding role of the anterolateral thigh free flap in head and neck reconstruction

PURPOSE OF REVIEW

To review the recent literature on the expanding use of the anterolateral thigh free flap for head and neck reconstruction.

RECENT FINDINGS

The versatility of the anterolateral thigh free flap allows it to be raised as a subcutaneous, musculocutaneous, fasciocutaneous, or adipofascial flap. In recent years, it has been reported to reconstruct defects involving the scalp, skull base, pharynx, tracheal stoma, oral cavity, and oropharynx. Various techniques have also been described in its harvest and inset, including combination flaps in conjunction with other free flaps or bone grafts, chimeric flaps, double-paddled skin flaps, and sensate flaps. These reports confer good functional and aesthetic outcomes equal to or better than other fasciocutaneous free flaps.

SUMMARY

The role of the anterolateral thigh free flap in reconstructing head and neck defects is ever expanding, with many novel harvesting and reconstructive techniques described in recent years. Because of the large surface area of the anterolateral thigh, as well as the ability to tailor variable amounts of skin, muscle, fat, or fascia associated with this flap, the reconstruction options are numerous. More importantly, good functional and aesthetic outcomes are achievable with an associated low morbidity of the donor site.